| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
984 |
984 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,745 |
1,745 |
$45K |
| D1120 |
Prophylaxis - child |
976 |
976 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,105 |
1,105 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
88 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
15 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$699.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$393.13 |